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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 3  |  Page : 83-86  

The effect of contrast administration on renal function after cardiac catheterization in Saudi patients


King Abdulaziz Cardiac Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Mohammed Ali Balghith
King Saud Bin Abdulaziz University for Health Sciences, Riyadh 11426
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_69_19

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   Abstract 


Background: The increase of serum creatinine by 25% from the baseline readings will lead to contrast-induced nephropathy. Most of the time this acute reduction in kidney function will occur in the first 48 h after angiogram; diabetes mellitus (DM) is one of the major predisposing factors.
Objectives: Our objective is to study the influence of contrast material administration during angiogram on kidney function, especially in patients with risk factors such as DM in the Saudi community.
Methods: This was an open-label study; we included 1250 patients from July 2010 to June 2011, and we studied all comers during that period; more than 60% of admissions came through the emergency department with acute coronary syndrome, in addition to elective admission with stable computer-aided design.
Results: The incidence of nephropathy related to the contrast used during angiogram was 4.8%, and this represents 60 patients of 1250. Of the 60 patients, the number of diabetic patients who developed nephropathy was 37 (62%). 40 (67%) patients were hypertensive. Twenty-five (42%) patients had body weight <70 kg, 37 (62%) had diagnostic cath, 23 (38%) underwent percutaneous coronary intervention, and 47 (78%) received Omnipaque contrast media.
Conclusion: The incidence of nephropathy postcoronary angiogram was 4.8%; the two major risk factors in our Saudi patients were hypertension and diabetes; the diabetic patients should be monitored precisely, and special measures should be taken seriously.

Keywords: Coronary angiogram, diabetes mellitus, hypertension, nephropathy, percutaneous coronary intervention


How to cite this article:
Balghith MA. The effect of contrast administration on renal function after cardiac catheterization in Saudi patients. Heart Views 2019;20:83-6

How to cite this URL:
Balghith MA. The effect of contrast administration on renal function after cardiac catheterization in Saudi patients. Heart Views [serial online] 2019 [cited 2019 Oct 15];20:83-6. Available from: http://www.heartviews.org/text.asp?2019/20/3/83/267847




   Introduction Top


Contrast-induced nephropathy (CIN) is defined as a sudden deterioration in kidney function.

Contrast media (CM) administration in catheterization laboratories is usually given by intra-arterial or by intravenous (IV) routes.[1] This problem of CIN was described many years ago by in 1954.[2] There was more report on this phenomenon; the incidence of CIN increased from the mid-1970s, corresponding with an increase in procedures that use the CM.[3]

The studies showed that there is an increase of serum creatinine by 25% from the baseline readings in the first 48–72 h after CM administration during coronary angiogram. This will lead to increase of both morbidity and mortality of those patients who underwent invasive cardiac procedures.[4]

There are many known risk factors for the development of CIN after either diagnostic or percutaneous coronary intervention (PCI), and the most important of which are baseline chronic renal impairment and diabetes mellitus (DM). Other risk factors include old age, anemia, heart failure, low volume status, dehydration, hypertension (HTN), renal transplant, low serum albumin, concomitant use of nephrotoxins, and the volume of the contrast agent. The prevalence of CIN is from less than 1% to 50%.[5]

Our objective was to study the effect of CM administration on kidney function and the relation of risk factors including diabetes which can predispose patients to CIN.


   Methods Top


This was an open-label, single-center study performed at the King Abdulaziz Cardiac Center, Riyadh, Kingdom of Saudi Arabia. We included all comers who underwent cardiac catheterization for either diagnostic or interventional procedures. The total number of patients was 1250 from July 2010 to June 2011. The vast majority of patients were admitted with acute coronary syndrome (ACS) through the emergency department.

Going by the usual practice in our cardiac unit, all elective admission and stable computer-aided design patients were started on IV fluids for at least 12–24 h prior cardiac catheterization procedure; the main purpose of fluid administration was to improve the volume status of our patients prior to CM exposure in the cath lab.

There may not be enough time to hydrate patients with acute ST segment elevation myocardial infarction who underwent primary PCI. However, patients with previous kidney function impairment and high serum creatinine will usually have IV fluid hydration for 2–3 days before the coronary angiography.

In our study, the measurements of serum creatinine were done as a routine in every patient 1–3 days before the procedure; postcath creatinine measurements were taken on the 1st day postprocedure, 2nd day, and 3rd day. Their medical record numbers were traced from the hospital computer database, and the analysis was done accordingly. All patients with documented kidney function deterioration were excluded including patients with end-stage renal disease on hemodialysis or peritoneal dialysis and kidney transplant before or planned at the time of the study.

In our cath lab, two CMs were used on a daily basis, Omnipaque and Visipaque iohexol. Omnipaque is a nonionic, monomer, 350 mgI/ml with a low osmolality of 884. The other CM was iodixanol (Visipaque) which is a nonionic, dimer, 320 mgI/ml with a low osmolality of 290.

The definition of renal impairment due to contrast media

We use the current definition of CIN which was defined as a 25% increase in the serum creatinine from the baseline reading in the 2nd–3rd day postcardiac cath.

Statistical analysis

Data were entered in Excel and analyzed using SPSS version 19.0 for Windows (SPSS, Chicago, IL, USA). Demographic characteristics are presented for continuous variables as means and standard deviations and categorical variables as frequencies and percentages. CIN and non-CIN patients were compared using the Chi-square test for categorical variables and Student's t-test for continuous variables. Significance was set at the 0.05 level.


   Results Top


A total of 1250 patients underwent coronary angiography; the mean age of the study cohort was 56.7 (±11.8) years; 988 (79%) patients were male; 763 (61%) had DM; 750 (60%) had HTN; 1062 (85%) had hyperlipidemia; and 438 (35%) had obesity [Table 1].
Table 1: Baseline characteristics and risk factors of the patients involved in the study (n=1250)

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The incidence of nephropathy related to the CM during angiogram was 4.8%. This represents 60 patients of 1250 [Figure 1]. Seven hundred and fifty-eight patients underwent diagnostic cath and 492 had PCI [Figure 2]. Of the 60 patients, the number of diabetic patients who developed nephropathy was 37 (62%) and 40 (67%) patients were hypertensive.
Figure 1: This figure showed the total number of patients who underwent coronary angiogram; 60 (4.8%) patients of them developed nephropathy postangiogram

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Figure 2: It showed the number and types of procedures done to the patient group during the admission

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Twenty-five (42%) patients had body weight <70 kg; 37 (62%) had diagnostic cath; 23 (38%) underwent PCI; and 48 (80%) received Omnipaque CM.

In this study, two types of CM were used. The number of patients who received Omnipaque contrast was 1107 - one hundred forty three (143 patients) received Visipaque [Figure 3]. Among the 60 patients who developed contrast nephropathy, the vast majority of patients (47, 78%) received Omnipaque.
Figure 3: This figure showed two types of contrast media given to the patients, Omnipaque and Visipaque during the study

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In those 60 patients who developed CIN 37 (62%) patients were diabetic. There was no significant difference in the development of nephropathy in diabetic and nondiabetic postcardiac catheterization; there were 40 (67%) hypertensive patients, and the difference between those hypertensive and nonhypertensive patients was statistically nonsignificant [Figure 4].
Figure 4: This figure showed no significant difference in both diabetic and hypertensive groups who had nephropathy

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   Discussion Top


This study is a single Saudi cardiac center experience; all patients without a contraindication to coronary angiogram were included, and the main results showed that the incidence of nephropathy after angiogram was 4.8% in this particular group. We found that the two major risk factors that precipitate this type of nephropathy were HTN and diabetes, with more incidence of renal impairment in the hypertensive patient group.

It is known that one of the main reasons of acute kidney injury (AKI) in hospitalized patients is exposure to CM and development of CIN. The incidence of CIN ranges between 0% and 25%, and this is mainly related to different risk factors.[5] Most of the time this phenomenon is a transient and reversible type of AKI. Unfortunately, this problem of CIN is associated with a longer hospital stay, and this might lead to increased morbidity and mortality; the cost of hospitalization will increase, and this will be a burden on the hospital budget.[6]

It is well known that CIN could happen as a complication of IV administration of iodinated CM, which is used commonly in the radiology departments for diagnostic or therapeutic purposes, such as interventional radiology. This is a major cause of renal failure in this setting of admitted patients.[7] In those cases, kidney failure is associated with both short- and long-term adverse outcomes.[8]

Previous studies and reports showed that CIN occurs in 4%–20% of patients after intra-arterial administration, especially in cardiac catheterization laboratories after coronary angiography and angioplasty.[9],[10] The vast majority of patients who underwent formal angiography including coronary angiography are admitted in the hospitals, and generally, a good number of them will be already on IV fluids; this will lead to a different physiologic status than ambulatory patients who are not well prepared and hydrated prior to their procedures.

The others, like patients coming through the emergency department, may be more likely to have uncontrolled renal stresses such as undiagnosed or untreated HTN or chronic hyperglycemia (DM), and they are less likely to be well hydrated. Moreover, hospitalized patients in a prolonged supine position may have a lowered rate of renin secretion, resulting in higher renal blood flow.[11]

There is a lot of argument about the clinical importance of nephropathy postcontrast administration (CIN), with different opinions; a good number of expert operators in this field think that the concept of contrast nephropathy is only an abnormal laboratory result of creatinine with only a little biological effect.[12]

The peak level of serum creatinine in the majority of patients with CIN is in the normal range or returns to normal within 1–3 weeks of contrast administration.[13] Treatment of this type of nephropathy is mainly conservative, consisting of careful fluid and electrolyte management; dialysis may be required in some of the cases.[14],[15] Due to limitation in the available management options, the role of prevention is the cornerstone of management.

Different approaches have been tried both pharmacological and nonpharmacological for the prevention of nephropathy postcontrast. Patients at high risk of developing CIN are patients with acute kidney insufficiency preexisting chronic kidney disease.

It is well known that reducing the volume and amount of CM, preventing dehydration, volume depletion, and avoiding activation of renal vasoconstriction are the most effective measures to prevent CIN. In addition, the concomitant use of diuretics or nephrotoxins (e.g., nonsteroidal anti-inflammatory drugs, cytotoxic drugs, and aminoglycosides) should be avoided.[16],[17]


   Conclusion Top


The incidence of nephropathy after coronary angiography in our study was 4.8%, and the two major risk factors in our patients were hypertension and diabetes.


   Recommendation Top


Diabetic patients should be monitored precisely, and special measures should be taken in this particular group.

Limitation

The major limitation for this study is that it was limited only to our cardiac center patients with noncontrol group for comparison.

Acknowledgment

We would like to extend our special thanks to all cardiac staff working at the Catheterization Laboratory Department, King Abdulaziz Cardiac Center (KACC).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bartels ED, Brun GC, Gammeltoft A, Gjørup PA. Acute anuria following intravenous pyelography in a patient with myelomatosis. Acta Med Scand 1954;150:297-302.  Back to cited text no. 1
    
2.
Katzberg RW, Lamba R. Contrast-induced nephropathy after intravenous administration: Fact or fiction? Radiol Clin North Am 2009;47:789-800, v.  Back to cited text no. 2
    
3.
Solomon R. Contrast-Induced Acute Kidney Injury (CIAKI). Radiol Clin North Am 2009;47:783-8, v.  Back to cited text no. 3
    
4.
Jabara R, Gadesam RR, Pendyala LK, Knopf WD, Chronos N, Chen JP, et al. Impact of the definition utilized on the rate of contrast-induced nephropathy in percutaneous coronary intervention. Am J Cardiol 2009;103:1657-62.  Back to cited text no. 4
    
5.
McCullough PA, Adam A, Becker CR, Davidson C, Lameire N, Stacul F, et al. Epidemiology and prognostic implications of contrast-induced nephropathy. Am J Cardiol 2006;98:5K-13K.  Back to cited text no. 5
    
6.
Perrin T, Descombes E, Cook S. Contrast-induced nephropathy in invasive cardiology. Swiss Med Wkly 2012;142:w13608.  Back to cited text no. 6
    
7.
Schräder R. Contrast material-induced renal failure: An overview. J Interv Cardiol 2005;18:417-23.  Back to cited text no. 7
    
8.
Briguori C, Tavano D, Colombo A. Contrast agent – Associated nephrotoxicity. Prog Cardiovasc Dis 2003;45:493-503.  Back to cited text no. 8
    
9.
Hou SH, Bushinsky DA, Wish JB, Cohen JJ, Harrington JT. Hospital-acquired renal insufficiency: A prospective study. Am J Med 1983;74:243-8.  Back to cited text no. 9
    
10.
Asif A, Preston RA, Roth D. Radiocontrast-induced nephropathy. Am J Ther 2003;10:137-47.  Back to cited text no. 10
    
11.
Solomon RJ, Mehran R, Natarajan MK, Doucet S, Katholi RE, Staniloae CS, et al. Contrast-induced nephropathy and long-term adverse events: Cause and effect? Clin J Am Soc Nephrol 2009;4:1162-9.  Back to cited text no. 11
    
12.
Gupta R, Gurm HS, Bhatt DL, Chew DP, Ellis SG. Renal failure after percutaneous coronary intervention is associated with high mortality. Catheter Cardiovasc Interv 2005;64:442-8.  Back to cited text no. 12
    
13.
Rudnick M, Feldman H. Contrast-induced nephropathy: What are the true clinical consequences? Clin J Am Soc Nephrol 2008;3:263-72.  Back to cited text no. 13
    
14.
Gami AS, Garovic VD. Contrast nephropathy after coronary angiography. Mayo Clin Proc 2004;79:211-9.  Back to cited text no. 14
    
15.
Raj SR, Biaggioni I, Yamhure PC, Black BK, Paranjape SY, Byrne DW, et al. Renin-aldosterone paradox and perturbed blood volume regulation underlying postural tachycardia syndrome. Circulation 2005;111:1574-82.  Back to cited text no. 15
    
16.
Chui WC. Contrast-induced nephropathy. Hong Kong Med Diary 2010;15:18-9.  Back to cited text no. 16
    
17.
Harjai KJ, Raizada A, Shenoy C, Sattur S, Orshaw P, Yaeger K, et al. Acomparison of contemporary definitions of contrast nephropathy in patients undergoing percutaneous coronary intervention and a proposal for a novel nephropathy grading system. Am J Cardiol 2008;101:812-9.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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  [Table 1]



 

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